DECEMBER 2014

CHAPTER 7: CLAIMS, BILLING, AND REIMBURSEMENT

UNIT 2: HEALTH OPTIONS SPECIFIC BILLING GUIDELINES

IN THIS UNIT TOPIC SEE PAGE

Specialty/Fee-For-Service Providers 2
Health Options Members with Medicare Coverage 3
Subrogation 5
Early And Periodic Screening, Diagnosis, And Treatment 6
(EPSDT) Services
Obstetrical Care Services 7
Surgical Procedure Services 8
Anesthesia Services 9

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7.2 SPECIALTY/FEE-FOR-SERVICE PROVIDERS

Encounter Health Options reimburses providers on a fee for service basis. Since there are no
submission capitated payment arrangements, there are no encounter reporting requirements.

Submitting to If a member has other coverage, the other carrier is always the primary insurer.
Health Options The specialist will bill the other insurer and the other insurer will issue payment
as secondary with an Explanation of Benefits (EOB) statement, which outlines the payment
payer made for each procedure. The specialist will then submit a copy of the EOB with a
copy of the claim to Health Options for secondary coverage.

The claim must be received by Health Options within sixty (60) days of the date of
the EOB. If required, all Health Options authorization requirements must be met in
order for payment to be issued.

Determining If the member has commercial insurance, and the commercial carrier’s payment is
Health Options greater than Health Options payment if Health Options were primary, then the
liability after following reimbursement example would apply. The primary carrier amount is the
primary carrier basis for the benefit determination of Health Options liability when the
practitioner is a participating practitioner with the primary plan. The primary
carrier allowable paid amount is used as the basis for the benefit determination of
Health Options liability when there is a patient responsibility remaining after the
primary carrier has processed the claim.

Example of Practitioner Participating with Primary Plan:

Practitioner Charges $1,500.00
Primary Carrier Allowable $1,000.00
Primary Payment (80% of Allowable) $800.00
Health Options Allowable if Primary $600.00
Health Options compares the Primary Carrier Payment to the Health Options Allowable $800.00 vs. $600.00
Health Options does not issue payment $0.00

Example of Patient Responsibility remaining after Primary Plan Payment:

Practitioner Charges $1,500.00
Primary Care Allowable $1,000.00
Primary Payment (80% of Allowable) $800.00
Patient Responsibility Under Primary Plan $200.00
Health Options Allowable if Primary $850.00
Health Options compares the Primary Carrier Payment to the Health Options Allowable $800.00 vs. $850.00
Health Options Issues Payment $50.00

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7.2 HEALTH OPTIONS MEMBERS WITH MEDICARE COVERAGE

Overview Health Options members 21 years of age or younger may have Medicare Fee For
Service. When Medicare is the other insurance, the following processing criteria
applies:
• Referrals and authorizations are not required for services covered by
Medicare. Once Medicare benefits have been exhausted, or if a service is
not covered by Medicare, authorization criteria will apply.
• For Medicare Part A and Medicare Part B services, coverage is provided
according to a benefits-less-benefits calculation.

Payment Health Options determines the amount that would normally be paid under the
calculations plan using the allowable amount from the Medicare Plan as the billed amount. If
the amount Health Options would pay is more than the amount Medicare pays,
then Health Options may pay the difference up to the maximum allowable,
contingent on the benefit-less-benefit calculation. If the amount Health Options
would pay is equal to or less than the amount Medicare pays, Health Options does
not issue any additional payment.

For Medicare services that are not covered by Medical Assistance or Health
Options, Health Options must pay cost sharing to the extent that the payment
made under Medicare for the service and the payment made by Health Options
does not exceed eighty (80) percent of the Medicare approved amount.

Examples EXAMPLE A
Practitioner Charges $1,500.00

Deductible is Satisfied -

Medicare Allowable $1,000.00

Medicare Payment (80% of Allowable) $800.00

Health Options Allowable if Primary $600.00

Health Options compares the Medicare Payment to the Health
$800.00 vs. $600.00
Options Allowable
Health Options does not issue payment $0.00

Continued on next page

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7.2 HEALTH OPTIONS MEMBERS WITH MEDICARE COVERAGE,

Continued

Examples EXAMPLE B
(continued)
Practitioner Charges $1,500.00

Deductible is Satisfied -

Medicare Allowable $1,000.00

Medicare Payment (80% of Allowable) $800.00

Health Options Allowable if Primary $850.00

Health Options compares the Medicare Payment to the Health
$800.00 vs. $850.00
Options Allowable
Health Options issues Payment for the Difference $50.00

EXAMPLE C
Practitioner Charges $1,500.00

Medicare Allowable $1,000.00

Medicare Applies $50.00 to Satisfy the Deductible $50.00

Medicare Payment (80% of Allowable) Remaining After
$760.00
Deductible is Satisfied
Health Options Allowable if Primary $850.00
Health Options compares the Medicare Payment to the Health
$760.00 vs. $850.00
Options Allowable
Health Options Issues Payment for the Difference $90.00

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7.2 SUBROGATION

Overview According to Health Options’ agreement with the Delaware Department of Health
and Social Services (DHSS), if a member is injured or becomes ill through the act of
a third party, medical expenses may be covered by casualty insurance, liability
insurance, or litigation.

Any correspondence or inquiry forwarded to Health Options by an attorney,

practitioner of service, insurance carrier, etc. relating to a personal injury accident
or trauma-related medical service, or which in any way indicates that there is, or
may be, legal involvement, will be handled by Health Options Legal Department
and will be forwarded to DHSS Third Party Liability Department.

Claims Claims submitted by a provider and without an Explanation of Benefits statement

submission from auto insurance or casualty plans without any notation on the original bill of
the primary payer, will be processed by Health Options similar to any other claims.
Health Options may neither unreasonably delay payment nor deny payment of
claims because they are involved in injury stemming from an accident, such as a
motor vehicle accident, where the services are otherwise covered.

Timely filing criteria of one hundred twenty (120) days applies and original claims
must be received timely to be eligible for payment. Explanation of Benefits or
auto/workers compensation/casualty exhaustion letters qualify for consideration
if they are received within sixty (60) days of the date of the Explanation of
Benefits/letter along with submission of the initial bill in order for Health Options
to coordinate benefits.

However, if the auto/casualty Explanation of Benefits is submitted after Health

Options has already paid as primary, claims cannot be adjusted, as Health Options
must comply with criteria set by DHSS.

Requests for All requests from legal representatives, and/or insurers for information concerning
information copies of patient bills or medical records must be submitted to Health Options
Legal Department.

A cover letter identifying the date and description of the injury, requested dates of
services for billing statements, and release of information signed by the member
should be forwarded to the following address:
Health Options
Attention: Legal/Regulatory Affairs
P.O. Box 22218
Pittsburgh, PA. 15222-0218

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7.2 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND

TREATMENT (EPSDT) SERVICES

Submit EPSDT All Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) screening
screens via services, including vaccine administration fees, should be submitted to Health
1500/837P Options either on a CMS-1500 or the corresponding 837P format for electronic
data interchange (EDI) claims within one hundred twenty (120) days from the date
of service.

Health Options cannot accept an EPSDT screen on a UB-04 or the

corresponding 837I format.

Guidelines An EPSDT screen is complete when codes from each service area required for that
age, including the appropriate evaluation and management codes, are
documented. Consult the current Children’s Checkup (EPSDT) Program Periodicity
Schedule and Coding Matrix as well as the Recommended Childhood Immunization
Schedule for screening eligibility information and the services required to bill for a
complete EPSDT screen.

With the exception of the dental component for clinics that do not offer dental
services, Federally Qualified Health Centers (FQHCs)/Rural Health Clinics (RHCs)
may not bill for partial screens.

Health Options uses fully automated coding review software. The software
programmatically evaluates claim payments in accordance with CPT-4, HCPCS,
ICD-9, American Medical Association (AMA), and Centers for Medicare & Medicaid
Services (CMS) guidelines as well as industry standards, medical policy, and
literature and academic affiliations.

Payment Claims will be paid at the provider’s EPSDT rate only if the appropriate evaluation
and management code and EP modifier are submitted.

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7.2 OBSTETRICAL CARE SERVICES

Reimbursed Obstetric practitioners are reimbursed on a per visit basis. All visits and dates of
per visit service must be included on the CMS-1500 Form or 837P and identified with
appropriate maternity codes for appropriate reimbursement.

Delivery Delivery charges are to be coded with CPT Codes. The date billed for a Delivery
charges Code, in CPT code format, must be the actual date of service. Health Options
payment allowance for the delivery includes all postpartum visits.

Newborn All charges for newborns that become enrolled in the plan are processed under
inpatient the newborn name and newborn’s Health Options identification number. For
claims prompt payment, please submit claims with the newborn patient information or
the claim will be pended for manual research.

Inpatient hospital bills for newborns should be submitted separately from the
mom’s confinement. Per diem payments for inpatient maternity services that
cover the confinement for both mom and baby will be issued under the mother’s
Health Options identification number and the newborn’s claim will be processed
for informational purposes only.

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7.2 SURGICAL PROCEDURE SERVICES

Payment Health Options reimburses surgical procedures in accordance with industry

limits standard protocols and limits payment to a maximum of three (3) surgical
procedures/operating sessions.

Reimbursement Health Options determines reimbursement upon the clinical intensity of each
procedure and reimburses at one hundred (100) percent for the most clinically
intensive surgery, and fifty (50) percent for the second and third procedures.

Pre- and post-operative visits will only be reimbursed to the extent that they
qualify for payment according to the follow-up criteria.

Assistant An assistant surgeon may bill for one (1) procedure per date of service, and will be
surgeon reimbursed at twenty (20) percent of Health Options maximum allowable fee, as
long as the surgical procedure code allows an assistant surgeon to be present for
the surgery.

If the assistant surgeon charges are submitted under the supervising physicians
name, the AS modifier indicating this was a physician's assistant must be
included on the claim.

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7.2 ANESTHESIA SERVICES

Anesthesia Health Options processes anesthesia services based on anesthesia procedure

procedure codes only. The claim should include only the primary anesthesia code except
codes when there is an add-on code that should be reported along with the primary
anesthesia service.

Units All services must be billed in minutes. Fractions of a minute should be rounded to
whole minutes (30 seconds or greater: round up; less than 30 seconds: round
down).

For billing purposes, the number of minutes of anesthesia time will be placed in
space 24G on the CMS-1500 for providers who bill in paper format.

Modifiers • Physical status modifiers, P1-P6, will not allow any additional payment.
• Health Options will not accept pricing modifier AA.

Additional • If you provide pain management services, continue to bill with surgical codes.
tips • If you provide medical procedures such as Swan Ganz, Laryngoscopy Indirect
with Biopsy, Venipuncture Cutdown, Placement of Catheter or Central Vein,
then continue to bill with the medical procedure code.
• When billing OB anesthesia codes 01960, 01961, 01962, 01963 and 01967, you
do not need to add an additional hour for patient consultation. The
Department of Public Welfare has already added 4 to the relative value unit
for these codes.
• When billing anesthesia for all obstetrical procedures, use the anesthesia
procedure codes as defined in the Anesthesia section of the CPT-4 manual.

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